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A B
Fig. 33.10 (A) Significant stenosis after open repair of injured popliteal artery (arrow). (B) Control angiography after stenting.
tolerance to hemorrhagic shock in comparison with
adults. Due to this, pediatric vascular injury requires more
aggressive and earlier intervention.
Several factors unique to children should be considered
during vessel repair. Firstly, the dimensions of the injured
vessels make surgical correction more complex and increase
the complication rate. Secondly, circumferential running
suture causes a “purse stringing” effect with further arterial growth. For this reason, interrupted suture repair that
allows for vessel development is recommended. Also, during
repair of injured vessels in children, surgeons should think
about the signicant risks of growth and development complications including limb-length disparities, claudication,
and decreased perfusion. There are signicant limitations
concerning the use of synthetic conduits or allografts due
to long-term patency concerns. On the other hand, vein
graft dilatation should be expected over time (Fig. 33.11).
This is why some authors suggest reinforcement of the vein
graft with synthetic mesh. Neointimal hyperplasia is potentially more frequent because of the longer time available for
this to develop in children compared with adults. From our
perspective, it seems reasonable to use endovascular techniques – at least as a bridge – in children with multiple associated injuries.
Lesson 13: Long-Term
Complications After Repair of
Vascular Trauma
Two of the long-term complications following the open repair
of injured arteries are true vein graft aneurysms and stenosis (due to neointimal hyperplasia). Endovascular repairs of
injured arteries can be complicated by early thrombosis and
distal embolism. The long-term results following endovascular repair of vascular trauma are unknown. Endograft migration, fracture, and stenosis caused by neointimal hyperplasia
are potential complications.
Conclusion
Endovascular repair has an important role in the treatment
of vascular trauma (e.g., blunt trauma of the descending
thoracic aorta and the intrathoracic segment of supraaortic brunches; hemostasis from surgically unapproachable
mid-to-small arteries; or failure after open repair). However, in the majority of cases, open surgery is the method
of choice.
386 SECTION 5 • Global Perspectives on Vascular Trauma
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B
Fig. 33.11 (A and B) Saphenous vein graft aneurysm developed
12 years after repair of an injured popliteal artery during childhood.
References
1. Soubbotich V. Military experiences of traumatic aneurysms. Lancet.
1913;2:720–721.
2. DeBakey ME, Simeone FA. Battle injures of the arteries in the World
War II. Ann Surg. 1946;123:534–579.
3. Rich N, Clagett P, Salander JM, Piščević S. The Matas/Soubbotich con-
nection. Surgery. 1983;93:17–19.
4. Davidovic L, Cinara I, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil
and war peripheral arterial trauma: review of risk factors associated
with limb loss. Vascular. 2005;13:141–147.
5. Fingerhut A, Lappaniemi A, Androulakis G, etal. The European expe-
rience with vascular injuries. Surg Clin North Am. 2002;82:175–188.
6. MacKenzie EJ, Bosse MJ, Kellam JF, etal. Factors inuencing the deci-
sion to amputate or reconstruct after high-energy lower extremity
trauma. J Trauma. 2002;52:641–649.
7. Dragas M, Davidovic L, Kostic D, et al. Upper extremity arterial
injuries: factors inuencing treatment outcome. Injury. 2008;40:
815–819.
8. Davidovic LB, Banzic I, Rich N, Dragaš M, Cvetkovic SD, Dimic A. False
traumatic aneurysms and arteriovenous stulas: retrospective analysis. World J Surg. 2011;35:1378–1386.
9. Feliciano DV, Herskowitz K, O’Gorman RB, etal. Management of vas-
cular injuries in the lower extremities. J Trauma. 1988;28:319.
10. Velinovic M, Davidovic L, Lotina S, et al. Complications of opera-
tive treatment of injuries of peripheral arteries. Cardiovasc Surg.
2000;8:256–264.
11. Davidovic L, Lotina S, Kostic D, etal. Popliteal artery war injuries. Car-
diovasc Surg. 1997;5:37–41.
12. Marković M, Davidović L, Kuzmanović I, Dragas M, Ilić N. Giant post-
traumatic pseudoaneurysm of the peroneal artery with arteriovenous stula and bular notch. Am Surg. 2009;75:627–629.
13. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin
North Am. 1983;63:539–565.
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15. Riambau V, Böckler D, Brunkwall J, etal. Management of descend-
ing thoracic aorta diseases. Eur J Vasc Endovasc Surg. 2017;53:
4–52.
16. Sladojevic M, Markovic M, Ilic N, et al. Open treatment of blunt
trauma of supra-aortic brunches. Case series. Ann Vasc Surg. 2016;31:
205–210.
17. du Toit DF, Strauss DC, Blaszczyk M, de Villiers R, Warren BL. Endo-
vascular treatment of penetrating thoracic outlet arterial injuries.
Eur J Vasc Endovasc Surg. 2000;19:489–495.
18. Shalhub S, Starnes WB, Tran NT. Endovascular treatment of axil-
losubclavian arterial transection in patients with blunt traumatic
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Israel
EITAN HELDENBERG and ELON GLASSBERG
Israeli hospitals, as part of the national health system,
offer advanced medical care, which includes vascular
surgery.
As in other developed countries, endovascular treatment
of peripheral arterial occlusive disease is replacing the “old“
surgical approach. For example, endovascular treatment
of aortic aneurysms, both simple and complicated, has
become the preferred mode of treatment. Enjoying one of
the highest life expectancies in the world, the demand for
vascular procedures among the Israeli population is on the
rise.1 To meet these demands, specialized vascular units
provide 24/7 immediate vascular treatment in every public
hospital in Israel, including trauma victims.
The principal characteristics of vascular trauma surgery
in Israel resemble those of other Western countries, with
both penetrating and blunt mechanisms as causes of vascular injuries. The rate of iatrogenic vascular injuries has
increased over the last decades, with the spread of minimally invasive techniques within specialties such as cardiology, vascular and general surgery.
Located in the Middle East (Fig. 34.1) and having had
to ght for its existence since its establishment in 1948,
Israel has a history of military conicts. Those military conicts, although uncommon, involved high intensity clashes
between the armies of the surrounding Arab states and the
Israeli Defense Forces (IDF). The experience from these conicts has been widely reported (both in the eld of general
trauma, as well as vascular trauma).3 Unfortunately, over
the years Israel has also been confronted with terroristrelated attacks and maintains, generally speaking, a high
state readiness (Fig. 34.2).
Most Israeli physicians are recruited to the IDF during
times of need as reservists. Practicing in civilian hospitals (the IDF does not operate hospitals, but relies on the
national health system), these physicians receive additional annual military-specic and trauma-related training by the IDF. Thus, the IDF’s surgeons (during times of
full-scale conict) are mostly drafted civilians. It is also
worth mentioning that the IDF provides Advance Trauma
Life Support (ATLS) training to almost every resident
in Israel, regardless of whether they are in the reserves.
These intimate collaborations between the Israeli civilian
and military medical services allow for the rapid adaptation of combat-related military medical professional lessons in the civilian arena.
Data from past IDF conicts demonstrated vascular
injury rates that resemble those reported by the US military in Afghanistan.
forward IDF teams and evacuated to the civilian trauma
centers. Rapid evacuation of the injured victims from the
scene to the nearest hospital is the most important factor
in those victims’ prognosis. The severely wounded were
4–6
The casualties were treated by
2
mostly airlifted,preferably by the Israeli Air Force (IAF)
combat rescue and evacuation unit (669), manned by
senior physicians (Fig. 34.3).
Since the early 1990s, a worldwide epidemic of terrorist attacks against civilians has been raging. Aimed
at creating large numbers of victims, inducing fear, and
causing chaos among nations, most attacks are conducted
using improvised explosive devices (IEDs) as shown in
Fig. 34.4.
Unfortunately, the literature regarding terror-related
trauma is anecdotal, with a large portion originating from
Israel and related to the experience gained from treating
the casualties of suicide bombings. In the early years of the
21st century,
ers targeting buses, semi-conned spaces (restaurants,
cafés, night clubs, etc.) and open spaces (outdoor cafés, bus
stops, and open markets) as shown in Fig. 34.5.
Unlike the “classic” civilian-related trauma, IED explosions present civilian trauma and vascular surgeons with
military (combat) type injuries. Heldenberg et al. described
the Israeli experience with terror-related vascular trauma
(TVT) in two studies.
related vascular trauma (NVT), a signicant difference
was found in the prevalence of vascular injuries (9.85% in
TVT casualties versus 1.1% in NVT, P < .01).14 Moreover,
the prevalence of severely injured patients (injury severity
score [ISS] 25+) was 3.3 times higher among TVT victims as
compared to NVT victims (51.4% and 15.5%, respectively),
probably reecting the massive tissue damage caused by
IEDs.16 This higher ISS is also testament to the importance
of expeditious evacuation of patients who otherwise would
not have survived. As most of the explosions took place in
the center of large cities, the proximity to level 1 trauma
centers and the availability of experienced vascular surgeons probably played a crucial role in their survival.
In addition to the classic manifestations of blunt, penetrating, and burn injuries, victims of explosion may also suffer
blast injuries. Projectiles, such as steel balls, nails, screws,
and nuts packed around an explosive substance, were also
frequently used by terrorists in Israel and caused devastating
penetrating injuries and increased mortality.
The severity of the injuries caused by explosions relates
to the proximity of the casualty to the explosion. The kinetic
energy of shrapnel is maximal closer to the center of the
explosion, thus increasing the risk of vascular injuries
for individuals in this zone. Peleg has shown that the pattern of civilian injuries in terrorist attacks is different from
those of military injuries, probably due to the difference
in the setting, evacuation times, and the lack of protective
gear worn by civilians. In general, civilians were found to be
more vulnerable to terrorist-induced injuries and suffered
higher mortality rates.
7–14
Israel experienced a wave of suicide bomb-
14
15,16
In comparison with non–terror-
7,9,13,14,16–18
22
16
19–21
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A
Fig. 34.1 Israel and neighboring countries.
Fig. 34.2 The ruins of a bus blown up by a suicide bomber in the mid-
dle of Tel Aviv, October 19, 1994.
B
Fig. 34.3 (A and B) Wounded civilian evacuated by the Israel Air Force
special combat rescue and evacuation unit—unit 669.
Fig. 34.4 Improvised explosive device.
The Israeli experience with TVT, such as with civilians
injured by IEDs, demonstrates the importance of a thorough
examination to exclude vascular injuries as part of the initial
assessment in terrorist attacks. In a multicasualty incident,
when decisions are typically based on clinical judgment, triage ofcers should consider the high probability of vascular
injury and maintain a high index of suspicion.
The high prevalence of vascular injuries among casualties from terrorist attacks, particularly civilian IED victims,
further demonstrates the importance of establishing and
maintaining a national vascular surgery–trauma system
that is ever-ready. Unfortunately, as bombings affect more
and more cities around the world, the lessons learned in
Israel since the 2000s are ever more relevant.
390 SECTION 5 • Global Perspectives on Vascular Trauma
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Fig. 34.5 The Maxim restaurant explosion by a suicide bomber in Haifa,
October 4, 2003.
References
1. Life expectancy and healthy life expectancy—data by country. The
World Health Organization. http://apps.who.int/gho/data/node.main.
688?lang=en. Retrieved 8 August 2020.
2. Martin JM, Long BW. Vascular trauma: epidemiology and natural history. In: Rutherford’s Vascular Surgery. 8th ed. Philadelphia, PA: Else-
vier Saunders; 2422–2426.
3. Rich NM. Historical and military aspects of vascular trauma (with
lifetime reections of Doctor Norman Rich). In: Rich NM, Mattox
KL, Hirshberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier
Saunders; 2004:3–7.
4. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH,
Rasmussen TE. The epidemiology of vascular injury in the wars in
Iraq and Afghanistan. Ann Surg. 2011;253:1184–1189.
5. Nigel T, Rasmussen T. Epidemiology of vascular injury. In: Rasmussen
T, Nigel T, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia: Elsevier
Saunders; 2015:13–20.
6. Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries
in an urban combat setting: experience from the 2006 Lebanon War.
Vascular. 2010;18:1–8.
7. Mayo A, Kluger Y. Terrorist bombing. World J Emerg Surg. 2006;1:33.
https://doi.org/10.1186/1749-7922-1-33.
8. Kluger Y, Mayo A, Soffer D, Aladgem D, Halperin P. Functions and
principles in the management of bombing mass casualty incidents:
lessons learned at the Tel-Aviv Sourasky Medical Center. Eur J Emerg
Med. 2004;11:329–334.
9. Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A, Israeli Trauma
Group. The special injury pattern in terrorist bombing. J Am Coll Surg.
2004;199:875–879.
10. Almogy G, Belzberg H, Pikarsky AK, Zamir G, Rivkind AI. Suicide
bombing attacks: update and modication to the protocol. Ann Surg.
2004;239:295–303.
11. Kluger Y, Mayo A, Hiss J, et al. Medical consequences of terrorist
bombs containing spherical metal pellets: analysis of a suicide terrorism event. Eur J Emerg Med. 2005;12:19–23.
12. Alci R, Ashkenazi I, Kessel B. Management of victims in a mass casu-
alty incident caused by a terrorist bombing: treatment algorithms
for stable, unstable, and in extremis victims. Mil Med. 2006;171:
1155–1162.
13. Aschkenazy-Steuer G, Shamir M, Rivkind A, etal. Clinical review: the
Israeli experience: conventional terrorism and critical care. Crit Care.
2005;9:490–499.
14. Almogy G, Mintz Y, Zamir G, etal. Suicide bombing attacks. Can exter-
nal signs predict internal injuries? Ann Surg. 2006;243:541–546.
15. Heldenberg E, Givon A, Simon D, Bass A, Almogy G, Peleg K. Terror
attacks increase the risk of vascular injuries. J Front Public Health.
2014;2(47). https://doi.org/10.3389/fpubh.2014.00047.
16. Heldenberg E, Givon A, Simon D, etal. Civilian casualties of terror-
related explosions: the impact of vascular trauma on treatment and
prognosis. J Trauma Acute Care Surg. 2016;81:435–440.
17. Peleg K, Aharonson-Daniel L, Stein M, etal. Gunshot and explosion
injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel. Ann Surg. 2004;239:311–318.
18. Ministry of Foreign Affairs. The nature and extent of Palestinian terrorism. Israel Ministry of Foreign Affairs, 2006. https://mfa.gov.il/
MFA/ForeignPolicy/Terrorism/Palestinian/Pages/Palestinian%20
terrorism%202006.aspx Accessed August 1, 2020.
19. Champion HR, Holcomb JB, Young LA. Injuries from explosions:
physics, biophysics, pathology, and required research focus. J Trauma.
2009;66:1468–1477.
20. Ramasamy A, Hill AM, Clasper JC. Improvised explosive devices:
pathophysiology, injury proles and current medical management. J
R Army Med Corps. 2009;155:265–272.
21. Kluger Y. Bomb explosions in acts of terrorism—detonation, wound
ballistics, triage and medical concern. Isr Med Assoc J. 2003;5:
235–240.
22. Peleg K, Jaffe DH, Israel Trauma Group. Are injuries from terror and
war similar? A comparison study of civilians and soldiers. Ann Surg.
2010;252:363–369.
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South Africa
KENNETH BOFFARD
Region-Specific Epidemiology
South Africa is a large country (1,200,000 km2), with a
population of about 60 million, of whom half live in the
urban environment and half live in the rural environment.
There is inevitably a wide difference in the availability of
general and specialized medical care as a result.
For many years, South Africa has had a background
of violence. Some of this can be attributed to the political
and other difculties of the Apartheid era, but a signicant
proportion is of criminal and intercommunity origin. The
trauma registry at Johannesburg hospital, which has been
in existence since 1984, reects that in 1984 of the 1000
major trauma resuscitations per annum (injury severity
score [ISS] greater than 15), some 300 injuries were penetrating in nature. In the 1980s these were predominantly
due to stab wounds and usually associated with alcohol.
Around the time of the advent of full democracy in 1994,
there was initially an upsurge in interpersonal violence,
partly due to the relatively free availability of rearms and
partly due to some initial instability in the political system
before the democratic elections. At that time, not only was
there an upsurge in the number of gunshot wounds but a
higher prevalence of wounds from high-energy assaultrie (AK-47) ammunition was found in both rural and
urban environments. By 1994, of the 2000 resuscitations
at Charlotte Maxeke Johannesburg Academic Hospital
(CMJAH), 1000 were penetrating, and by 1999, there were
2500 resuscitations of which 2000 were penetrating, the
majority of which were gunshots. At the two major university teaching hospitals in Johannesburg (Chris Hani Baragwanath Academic Hospital [CHBAH] in Soweto and CMJAH
in central Johannesburg [Fig. 35.1]), the incidence of penetrating trauma was approximately 85% of all trauma victims. Of these, 70% were secondary to gunshot injuries.
Most of the remaining injuries were due to stabbing.
Since 1994, government focus has been on bringing
primary health care to poorer people, especially in rural
areas. The money has had to come from somewhere, and,
despite dramatic increases in total budget, famous urban
hospitals like CHBAH, and Groote Schuur in Cape Town fell
into neglect while hundreds and thousands of rural dwellers received some medical attention, many for the rst time
in their lives. The distances to major facilities are, however,
unchanged, and air transport is limited.
Since 2009 (apart from drug and gang related violence),
there has been a decline in the homicide rate across the
country. Stringent rearm laws including a background
check and a practical certicate of competency prior to
licensing, as well as a mandatory jail sentence for possession of an unlicensed rearm, have seen a signicant reduction in the use of rearms. There has been a slight increase
in the number of stabbings, but overall, particularly in the
Johannesburg area, both the homicide rate and the incidence of penetrating injury has dropped, in some cases by
up to 70%. In 2011, the same trauma registry showed 2200
cases overall, of which 900 were penetrating. In the University’s private Milpark Academic Trauma Centre, out of 1200
cases per year, the percentage of gunshots has dropped from
60% to less than 10%, and penetrating injury to less than
25% overall. The incidence of gunshot injuries in the Cape
Town and Durban areas has not shown such a dramatic falloff, but this may be partly due to increased use of rearms
secondary to an increased gang culture and drug culture. It
is now rare to see any high-energy rie injuries.
A substantial number of vascular injuries seen in the
South African context present late, with other competing injuries, and patients are in hypovolemic shock. The
patients’ outcome may also be compromised by the high
prevalence of HIV.
The common mechanisms of injury in blunt trauma are
similar to other countries and are related to long bone fractures, direct blows to the neck, and compression injuries.
Many are industrial related. South Africa has a very high
incidence of pedestrian injuries from motor vehicles, with
associated pelvic, femoral, and lower limb fractures, many
of which are associated with vascular injury as well.
Other injuries seen include strangulation, animal bites
(a different form of penetrating injury, Fig. 35.2), ejection
from motor vehicles, and an association between high cervical fractures and fractures involving the foramen transversarium, associated with blunt internal carotid artery injury.
In penetrating trauma, currently 50% of vascular injuries are gunshot-wound related and are particularly common in the neck and torso, with transmediastinal injury,
transabdominal injury, and injury to the femoral vessels.
The bulk of stab wounds causing vascular injury are to be
found in the neck, particularly zone I and zone II (in association with aerodigestive injuries, Fig. 35.3)
A relatively large number of patients with stab wounds to
the heart survive to reach the hospital and our experience,
like similar series from elsewhere, has been that, if they survive to reach hospital alive, they are likely to leave the hospital alive. A separately described subset of injury is that of
patients presenting with a repeat stab heart!
Finally, South Africa has a signicant gold and coal mining industry. The deepest mines are found about 50 miles
(80 kilometers) to the west of Johannesburg in the West
Wits Goldeld (Tau Tona and Mponeng mine). Active mining takes place at up to 5000 m/17,000 feet (about 3 miles)
below ground level. At this depth, the uncooled temperature of the rock can reach 67°C/150°F and the air pressure
can reach more than twice that at sea level. Rock movement
is common. The mining industry has an excellent safety
record, but the challenges of the injuries caused include
rock falls causing crush and compartment syndromes, often
1–4
.
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Fig. 35.1 Emergency Medical Services (EMS) helicopter flying past
Charlotte Maxeke Johannesburg Academic Hospital and metropolitan
Johannesburg.
Fig. 35.3 Penetrating injury to zone 1 of the chest. Knife still in place.
complicated by the long periods (up to 2 hours) required to
reach the surface.
Reliable follow-up is often difcult in South Africa and
treating minimal injury conservatively (nonoperatively) is
not always either feasible or possible. There is an associated
shortage of high-care beds, so many injuries that would no
longer be operated on elsewhere are dealt with surgically,
including with the use of endovascular techniques. Longterm follow-up is difcult in institutions in South Africa,
particularly after trauma, mainly because of socioeconomic factors. It is expected that only approximately onethird of patients will return to clinic visits within 2 months
of discharge.
Fig. 35.2 (A) Hippopotamus bite to the left side of the neck, with damage to the carotid and jugular vessels. (B) Same patient showing laceration of the shoulder, and crush injury to the back.
Region-Specific Systems of Care
There is approximately 1 physician for 25,000 patients in
the rural areas, and 1 physician per 700 patients in the
urban areas of South Africa. There are approximately 50
registered subspecialist vascular surgeons and 35 registered subspecialist trauma surgeons for the country, almost
all concentrated in the urban areas, and most in Academic
centers.5 There are some 800 practicing general surgeons
nationwide, mostly in the major centers, and it is they who
bear the brunt of the vascular trauma load.
Currently there are eight medical schools in South Africa,
producing 2000 graduates per annum. Unfortunately, 700
doctors leave the country each year primarily to Canada
and Australia, many of whom have already trained as specialists, including surgery. Thus, there is a signicant shortfall of medical practitioners in general, and of surgeons,
in particular. Although qualied general surgeons provide
the full range of trauma care in most instances, select cases
requiring subspecialty care or techniques (e.g., endovascular stent grafts) may be referred to subspecialty vascular or
trauma centers. By its very nature and urgency, a good deal
of trauma is dealt with by general surgeons, or even general
practitioners in regional or district hospitals.
There is a thriving private health sector, which inevitably
spends considerably more of the national health dollar per
patient than the state sector. In general, private facilities
are better equipped and staffed; and many centers are capable of advanced surgery (e.g., stereotactic neurosurgery,
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cardiac and lung transplantation). Diagnostic imaging
is usually far superior and more accessible at these private facilities, as is endovascular and minimally invasive
surgery. A substantial proportion of the population (up
to one-third) are covered by private health insurance, by
a gasoline tax if the victim is injured in an automobile
accident, and by a workman’s compensation insurance
scheme. Thus, a signicant amount of trauma will be
dealt with by the private sector; and, indeed, the rst two
level I trauma centers accredited by the Trauma Society of
South Africa were fully privately funded.
Much rural surgery, both basic surgery and obstetric surgery, is performed by general practitioners. Although there
is a mix of public and private facilities across the country,
the reality is that most trauma, particularly outside the
major city centers, is dealt with in the public sector hospitals by government-employed doctors or “Medical Ofcers,”
many of whom are quite junior and lack senior backup,
adequate infrastructure, and may have neither appropriate
training nor adequate supervision.
As with many other developing countries, prehospital
care in the major cities is good in parts, with a combination of public and private ambulance services, paramedics,
linked road and air ambulances, and an integrated system
of care. However, in the rural areas, the level of training is
often poor, the vehicles are ill equipped, and the distances
long, resulting in interhospital transport times of up to
8 hours. Like Australia, many parts of the country are
served by a rural ying doctor service, though sometimes
during daylight hours only.
Techniques of Care
There is considerable emphasis on short courses to
upgrade trauma care and the recognition of vascular
injury. The Advanced Trauma Life Support program
(ATLS) of the American College of Surgeons has been in
place since 1978. In addition to the specialist fellowships
such as surgery (usually 5 years), and subspecialty fellowships such as vascular surgery, and trauma surgery with
trauma critical care (usually 2 years further), the College
of Medicine of South Africa also offers a 2-year Higher
Surgical Diploma to provide extra preparation and support for rural general practitioners involved in basic general surgery, including life-saving surgery such as damage
control surgery.
The Denitive Surgical Trauma Care (DSTC) Course of
the International Association for Trauma Surgery and
Intensive Care (IATSIC) has been very popular, with some
1000 surgeons and surgical medical ofcers now trained
in advanced emergency surgical life- and limb-saving techniques, including damage control, vascular shunting, and
basic vascular repair.
The technique of resuscitative endovascular balloon
occlusion of the aorta (REBOA) is in some use, though the
cost is prohibitive within the state sector. As a result, the
technique still must nd a dened place in South Africa, as
to date, it is primarily used in the tertiary hospitals to “buy
time” in Obstetrics and Gynecology, and some penetrating trauma. The technique is not used in the prehospital
environment.
7
6
Fig. 35.4 Patient with a stab wound of the neck showing the use of the
Foley catheter for tamponade.
MANAGEMENT OF ACUTE VASCULAR
HEMORRHAGE
There is emphasis on arresting hemorrhage with conventional techniques and sometimes with tamponade,
using adjuncts such as the Foley catheter.8 This technique
has proven useful, especially in stab wounds of zone I of
the neck, allowing transfer to a more appropriate center
(Fig. 35.4).
The surgical tourniquet (perhaps because South Africa
does not have the recent combat experience of the Middle
East and Afghanistan) is not in frequent use. The penetrating wounds are generally low-energy gunshot wounds or
stab wounds, and almost all can be controlled by direct pressure or using a blood pressure cuff.
MANAGEMENT OF ACUTE ISCHEMIA
Failure to recognize acute ischemia, especially in blunt
injuries, remains a challenge, and limb ablation as a result
of delays in both recognition and patient transfer remains
a real issue. Rehabilitation facilities in the state sector are
often rudimentary.
Region-Specific Considerations for
Diagnosis
Many of the same considerations referred to previously in
training and care delivery also apply to diagnostic imaging.
In major urban hospitals, the computer tomography angiogram (CTA) is usually the diagnostic method of choice, often
associated with simplex or duplex Doppler imaging. Magnetic resonance angiography (MRA) is generally available
as well. Interventional angiography is less readily available.
The technique of emergency room angiography, although
well-described, is practiced by very few centers.
The use of the low-dose digital x-ray unit (Lodox; www.
lodox.com, Fig. 35.5), a South African-developed unit
originally created for detection of swallowed diamonds in
the mining industry, is very fast and effective (Fig. 35.6).10
The Lodox can produce a high-quality digital whole-body
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Fig. 35.5 Photograh of the Lodox unit.
Fig. 35.6 A Lodox whole-body scan showing an impalement injury.
x-ray in as little as 13 seconds, at an ultralow-radiation
dose. Its use has halved total resuscitation times, and at our
center, is installed in the resuscitation unit room itself, so
that all x-rays are complete within 120 seconds of arrival,
and no further x-rays are routinely required.
Particularly with the use of the Lodox unit, emergency
room angiography using a contrast dose of as little as 20 mL
over the same period allows high-quality limb angiograms
(Fig. 35.7).
However, in the rural areas, even 24-hour general x-rays or
hand-held Doppler units are not readily available, and therefore diagnosis is primarily clinical with transfer to the nearest
appropriate center. These transfers are frequently associated
with delays and subsequent limb loss. Rehabilitation facilities
are few and far between, and, although available at a very
advanced level to the mining and private sector, they are not
commonly available to the vast majority of patients.
Region-Specific Treatment
Strategies
Fig. 35.7 Photograph showing a limb arteriogram performed on
the Lodox.
Commercially available self-expanding stent graft is a logical choice where there is incomplete arterial disruption and
separation, and where the angiographic capabilities and
endovascular grafts are available.
NECK
Management of penetrating wounds of the neck has favored
selective conservatism in Johannesburg for at least two
decades, although one incentive for pursuit of a nonoperative policy is the heavy trauma load presenting in our hospitals, together with comparatively limited resources. This is a
two-edged sword, as the number of operating rooms available is often outstripped by demands on them, and the origin
of the selective nonoperative policy was that several patients
became asymptomatic and recovered while awaiting surgery!
Of those patients observed with penetrating neck wounds,
6% to 9% had delayed surgery within 24 hours for missed
injuries, usually esophageal or laryngeal injuries. Duplex
Doppler is used to follow-up minor carotid injuries, identied angiographically, that are not operated on. It is generally agreed that surgical intervention should be reserved for
unstable patients with zone I and zone III injuries, patients
with ongoing bleeding, and patients requiring exploration
for other injuries. With other cases they are treated noninvasively or with endovascular techniques.
11,12
The treatment of vascular injuries follows the same techniques, using the same equipment, as in most Western
countries, including primary repair, vein patching, and
interposition grafts using either vein or synthetic graft.
CERVICOMEDIASTINAL INJURIES
Cervicomediastinal venous trauma can be very difcult
to control.
13–15
In a series of 49 patients, 45% of whom
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